Monthly Archives: May 2012

Results reinforce need for improved ‘survivorship care’ to encourage patients to seek help for their symptoms

CHICAGO – New data from an Internet-based study show that patients with head and neck cancers (HNC) may be at risk for significant late effects after their treatment, but they’re unlikely to discuss these and other survivorship care issues with their doctors. The findings, from researchers at the Perelman School of Medicine at the University of Pennsylvania, will be presented Monday, June 4, at the 2012 American Society of Clinical Oncology (ASCO) meeting in Chicago. The research team says the study reinforces the need to improve survivorship care for patients as they complete their active treatment, better educate patients about late effects they may experience, and encourage them to report these problems to their healthcare providers so they can be addressed.

Data from nearly 4,000 cancer survivors were gathered between April 2010 and October 2011 via patients who completed LIVESTRONG Care Plans via OncoLink, Penn Medicine’s online cancer resource. Approximately four percent of those patients had been treated for a primary head or neck cancer. Of those, nearly 88 percent reported having undergone radiation, 73 percent surgery, and 67 percent chemotherapy. Many patients reported late effects such as difficulty swallowing/speaking (83 percent), decreased saliva production (88 percent), thyroid problems (33 percent), decreased neck mobility (60 percent), concerns regarding cognitive function (53 percent), or vision deficits. However, since results show that patients only discuss the survivorship care plans they created on the site with their healthcare providers in 55 percent of cases, the researchers are concerned that many of these symptoms are not being reported or treated. The most common reasons for patients not sharing their survivorship care plans with healthcare providers were, “I did not think they would care,” and “I did not want to upset or anger them.”

“The fact that only about half of patients who create care plans are discussing them with physicians indicates a need for further development of patient counseling and survivorship care so we can deliver higher quality care to cancer survivors of all kinds,” says lead author Christine E. Hill-Kayser, MD, an assistant professor of Radiation Oncology in the Perelman School of Medicine. “Our study indicates that as many as 45 percent of these late effects are going unreported, so it’s possible that HNC patients may be at a higher risk for post-treatment side effects than we thought. But without understanding the true incidence of these problems, we can’t properly screen for these problems or intervene to help patients when they develop them.”

Patient-reported data were gathered from HNC survivors voluntarily using the LIVESTRONG Care Plan, a free Internet-based tool used to create survivorship care plans. The tool, available at www.livestrongcareplan.com and through the OncoLink website, allows survivors to enter data regarding diagnosis, demographics, and treatments, and provides customized guidelines for future care and screening. Using this tool, HNC survivors were asked about any late effects they experienced following specific treatments. The authors say data reported in the new study may help shape future studies examining outcomes after HNC treatments, as well as patient counseling and survivor care plans.

Penn’s Living Well After Cancer (LWAC) Program, for adult and childhood cancer survivors, is a LIVESTRONG Survivorship Center of Excellence. This designation, awarded by the Lance Armstrong Foundation, reflects excellence in clinical care, research and education. Within the LWAC Program, the same nurse practitioners who care for patients during their diagnosis and treatment help them develop an individualized survivorship care plan at the end of their treatment that guides patients if and when they transition back to their primary care or specialty provider for follow-up care.

“There’s a very clear lack of communication between patients, oncologists and primary care physicians, which can ultimately have a major impact on our patients’ long-term health and well-being, particularly if they are experiencing significant late effects of treatment,” said Hill. “It’s vital to our patients’ long-term survival and our ability to provide guidance to them that physicians better educate patients about what they might experience following treatment and encourage patients to raise any concerns or health issues they experience.”

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

Pioneering surgery which allows doctors to remove cancer in the mouth using a minimally invasive technique is now available at the Wellington Hospital.

Traditionally, the only way to remove Squamous Cell Carcinoma – cancer of the oropharynx which encompasses the tonsils and base of the tongue – has been to split the jaw, take out the cancer and repair the neck with tissue from the forearm.

This 10-hour procedure requires two surgical teams and often has complications. Patients are in hospital for at least three weeks and need months of rehabilitation to help them swallow and speak again.

Because the treatment is so invasive, many doctors try to avoid it using chemotherapy and radiotherapy instead. However, surgery is often the best chance of a cure.

The new one-hour technique called Transoral Robotic Surgery allows the cancer to be removed without splitting the jaw or taking tissue from other parts of the body. Instead, the tonsils are accessed through the mouth using a specially designed robotic machine.

Developed in the US in 2009 and now approved by the American Food and Drug Administration and licensed for use in the UK, it uses the Da Vinci robot to access this difficult to reach area.

It gives the surgeon greater precision, dexterity and accuracy while carrying out the procedure and the patient has no stitches. Infection rates are reduced which speeds up recovery rates, patients are in hospital for just a week and are able to swallow normally soon afterwards and require no long-term feeding tubes.

Neil Tolley, a Consultant Head and Neck Surgeon at the Wellington Hospital, who is now carrying out the new technique, says: “The mouth is a small place. The da Vinci robot allows access to anatomical sites and permits surgery to be performed which would otherwise be technically very difficult or impossible to perform conventionally.

“On the patients treated so far, the swallowing outcomes have been excellent with no need for a gastrostomy tube to feed them, yet the same cure rates have been achieved.”

Advaxis is announcing the enrollment of patients into the REALISTIC Phase I/II trial sponsored by Cancer Research UK to evaluate ADXS-HPV for the treatment of HPV-positive head and neck cancer. HPV has been linked to as many as seventy percent of all head and neck cancers.

ADXS-HPV is a next-generation immunotherapy that acts as a therapeutic vaccine and is being tested in trials against HPV-associated diseases, including cervical cancers.

The REALISTIC trial is being carried out at the Aintree Hospital at the University of Liverpool, the Royal Marsden Hospital at the University of London, and the Cardiff Hospital at the University of Wales. Qualified patients will have already received treatment for head and neck cancer, either surgery, radiotherapy, chemotherapy, or a combination of treatments.

Head and neck cancers account for roughly three percent of all cancers in the US, according to the American Cancer Society. They are more commonly diagnosed in men than women, and while they are traditionally linked to smoking and to alcohol consumption, HPV-related oropharyngeal cancers are on the rise among white males under 50 years of age.

“We are pleased to be working with an internationally-renowned oncology group to further expand the ADXS-HPV clinical development program to another HPV-associated tumor type,” said Advaxis Chairman & CEO Thomas A. Moore. “Through this collaboration, we hope that our proprietary technology will be able to offer a new treatment option to patients suffering from the recurrence of head and neck cancer, an important unmet medical need.”

May 23, 2012 — Suicide rates among patients with oral cavity and oropharyngeal (OC/OP) cancer have increased significantly over the past three decades, particularly among male patients during the first year after diagnosis.

As many as half of patients with head and neck cancer suffer from depression, among the highest of all oncology patients (Clinical Advances in Hematology & Oncology, June 2009 Vol. 7:6, pp. 397-403). However, despite documented high rates of depression and suicide among patients with head and neck cancer, studies examining suicide and other noncancer-related deaths in patients with OC/OP have not been published.

This gap prompted researchers from the New York Eye and Ear Infirmary, New York Medical College, and Peking University to analyze 32,487 patients with OC/OP cancer using the Surveillance, Epidemiology, and End Results cancer registry data for 1980-1984, 1990-1994, 2000-2003, and 2004-2007 (Archives of Otolaryngology-Head & Neck Surgery, January 2012, Vol. 138:1, pp. 25-32).

They found that from 1980-1984 to 2004-2007, deaths from suicide increased by 406.2% (p = .01), while cardiovascular disease-related and pneumonia-related deaths decreased by 45.9% (p < .001) and 42.9% (p = .009), respectively. Risk factors for mortality included age (55-64), marital status, advanced tumor stage, and tumor location.

The researchers also calculated standardized mortality ratios (SMRs) for suicide, cardiovascular disease, and pneumonia and compared them with patient demographic and clinical characteristics.

The risk of death from suicide or heart disease was highest during the first year after the cancer diagnosis and subsequently decreased with time, the researchers found. Compared with the general population, the increased risk of suicide was SMR 7.8 during the first year, SMR 3.7 during the second year, and SMR 2.5 during the third year.

Male-specific trend

Interestingly, during the three years after OC/OP cancer diagnosis, the researchers found no suicides among female patients, while 32 male patients took their lives.

Prior studies of the suicide risk among all patients with cancer have found similar rates among males and females, the study authors noted (Public Health Reports, Sept-Oct 2010, Vol. 125:5, pp. 680-688). When compared with males with prostate cancer, however, risk of suicide in male patients with OC/OP cancer was approximately five times higher in the first year after cancer diagnosis, the researchers noted.

“To be the subject of people’s stares, it is devastating to have that happen to you.”
— Brian Hill, executive director, Oral Cancer Foundation

Brian Hill, executive director of the Oral Cancer Foundation, had stage 4 bilateral cervical lymph node metastases when his OP cancer was discovered. He was not surprised by the study’s finding that only men committed suicide.

“Women are tough,” he told DrBicuspid.com. “Men are driven very much by our male egos, and part of having a cancer which deforms you and limits you in many ways is that it really impacts your ego.”

OC/OP cancer affects speech, swallowing, and breathing, as well as appearance, and can lead to devastating effects on quality of life, the study noted. For Hill, having the right side of his neck and the musculature in his mouth removed during surgery deeply affected him.

“There’s this whole thing about my image and who I am,” he explained. “You take away part of my face, take away part of my neck, take away my ability to speak distinctly, take away the things which I identify as me, and it changed my self-perception. For some people they’d rather not be alive. To be the subject of people’s stares — it is devastating to have that happen to you.”

Emotional support critical

Marital status also played a role in the study findings, with unmarried, divorced, and separated patients demonstrating a significantly higher risk than their married counterparts, the authors noted. Most of the men were aged 55-64 who never married or were divorced, separated, or widowed; had advanced tumor stages; and did not receive treatment.

For Hill, having the support of his wife was crucial in helping him cope with the disease. “I would not have gotten through it without her,” he said.

Counseling to help OC/OP cancer patients cope with the impacts of the disease is also critical, Hill added.

“This is a psychological journey you have to go on,” he said. “You need good intervention and good support from your family or our 8,000-member support group to cheer you on, encouraging you to get back out and be part of our community, find purpose in life.”

Increased recognition of major depression among patients with OC/OP cancer may create opportunities for psychiatric and/or pharmacologic intervention, the researchers concluded, leading to improved quality of life and, potentially, a reduction in suicide mortality.

Hill says antidepressants definitely helped him deal with his cancer and that more doctors should be aware of the psychological impacts of the disease.

“You’d be surprised how many oncologists are only interested in getting rid of the disease and don’t treat the human being,” he observed. “I wanted to put my head in the oven too at some points, and if it hadn’t been electric I would have.”

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

Keith Hern was diagnosed with throat cancer and his story is captured in the book Bangers and Mash. In this video Keith talks frankly and honestly about the moment that changed his life forever – when he found he had cancer.

Women who consume high volumes of folic acid found in vitamin B from vegetables and some fruits are less likely to suffer from mouth cancer. A sample of 87,000 nurses were followed for 30 years from 1976 by researchers from the Columbia University Medical Centre and Harvard School of Public Health.

Women who drank a high volume of alcohol and had low folic acid intake were three times more likely to develop mouth cancer than those who drank high volumes of alcohol but had high volumes of folic acid in their diet. Alcohol is one of the major risk factors for mouth cancer and those who drink to excess are four times more likely to be diagnosed.

This is the first time that folic acid intake has been shown to affect the risk of the disease. Alcohol leads to a reduction in folic acid metabolism by creating acetaldehyde which leads to a reduction of folic acid in the body.

Chief executive of the British Dental Health Foundation, Dr Nigel Carter, said: ‘Rates of mouth cancer in women have been increasing for many years as a result of changed social habits with more women smoking and drinking.

‘This new research could offer a method to reduce this by looking at the folic acid intake and increasing fruit and vegetables containing folic acid in the diet.

“In the past studies have tended to focus on males, as they are twice as likely to suffer from the disease. While this study focuses on women we know that men also benefit from the protective value of increased fruit and vegetables.”

Folic acid or vitamin B9 is essential to an individual’s health by helping to make and maintain new cells.

Pregnant women are advised to supplement their intake of folic acid, to ensure a healthy development of the baby. Folic acid is found in vegetables such as spinach, asparagus, beans, peas and lentils and is added to bread. Fruit juices, broccoli and brussel sprouts contain smaller amounts.

An unhealthy diet has been linked with around a third of mouth cancer cases.

Recent research has also shown that an increase in food such as eggs and fish that contain omega 3, and nuts, seeds and brown rice, which are high in fibre, can help decrease the risks.

Mouth cancer survival is poor with only around half of cases surviving for 5 years and this is due to late presentation.

Early warning signs to look out for include a mouth ulcer that has not healed within three weeks, red or white patches in the mouth and any unusual swelling or lumps in the mouth.

These are all signs that you should get your dentist or doctor to check you out as soon as possible.

A virus spread by oral sex may cause more cases of throat cancer in men than smoking, a finding that spurred calls for a new large-scale test of a drug used against the infection. Researchers examined 271 throat-tumor samples collected over 20 years ending in 2004 and found that the percentage of oral cancer linked to the human papillomavirus, or HPV, surged to 72 percent from about 16 percent, according to a report released yesterday in the Journal of Clinical Oncology. By 2020, the virus-linked throat tumors — which mostly affected men — will become more common than HPV-caused cervical cancer, the report found.

HPV is known for infecting genitals. The finding that it can spread to the throat and cause cancer may increase pressure on Merck & Co., the second-largest U.S. drugmaker, to conduct large-scale trials to see if its vaccine Gardasil, which wards off cervical cancer in women, also prevents HPV throat infections.

“The burden of cancer caused by HPV is going to shift from women to men in this decade,” Maura Gillison, an oncologist at Ohio State University and study senior author, said in a telephone interview. “What we believe is happening is that the number of sexual partners and exposure to HPV has risen over that same time period.”

Gillison said she worked with researchers at Whitehouse Station, New Jersey-based Merck several years ago to design a study in men. After Merck acquired Schering-Plough Corp. in 2009, though, the trial “was canceled,” she said.

No Further Study
Pamela Eisele, a spokeswoman for Merck, said the company decided not to move ahead with a big oral cancer study “due to competing research and business priorities.” GlaxoSmithKline Plc (GSK) has “no plans” to study the company’s competing vaccine Cervarix outside of cervical cancer, Jennifer Armstrong, a company spokeswoman, said in an e-mail.

Gardasil is approved for preventing cervical, vaginal and anal cancers and genital warts, and is recommended for girls and women ages 9 through 26. It is also approved for preventing genital warts and anal cancer in boys and young men of the same ages. Glaxo’s Cervarix is approved for preventing cervical cancer in females ages 9 through 25.

HPV-linked throat cancers, or orophyaryngeal cancer, are increasing so rapidly that by 2020 there will be 8,700 U.S. cases, with 7,400 cases in men, versus 7,700 cases of cervical cancer, the study said. Male cases alone will outnumber cervical cancer cases soon after 2020, Gillison said. The Ohio State study is based on tumor samples from several U.S. states.

HPV Infections
Roughly 20 million Americans have genital HPV infections, according to the Atlanta-based Centers for Disease Control and Prevention. At least half of sexually active women and men get it at some point in their lives, the CDC says. Most of the time it doesn’t cause health problems.

Until recently, head and neck cancer mainly occurred in older patients and was associated with tobacco and alcohol use. The HPV-linked head and neck cancers, usually of the tonsils, palate or tongue, hit men their 30s, 40s, and 50s, Gillison said. It is unclear why women are affected much less often than men, she said.

The decline in HPV-negative oral cancers mirrors the decline of smoking in the U.S., the study said.

Treatment involving chemotherapy, radiation and sometimes surgery, “is very nasty,” said Gillison. “It can leave people with permanent physical disfigurement, difficulty with speech and swallowing and poor dental health.”

Research Effort
Gillison started researching the oral cancer epidemic more than a decade ago as a fellow at Johns Hopkins University. Another researcher told her about a report from Europe of a case of oral cancer that was HPV positive, she said.

“I started working on it immediately,” she said.

In a 2007 epidemiology study published in the New England Journal of Medicine, Gillison and her colleagues found that having a high number of oral or vaginal sex partners are risk factors for HPV-associated throat cancer. The cancer may also be spread by open-mouth kissing, Gillison said in the interview.

“Nobody paid attention to oral HPV infections until 2007,” she said. “We are about 15 years behind in the research” compared with the data on cervical cancer and HPV, she said.

An editorial accompanying the study concluded that trials to see whether vaccines prevent oral cancer “are needed, given that prevention through vaccination will almost certainly be the ultimate solution” to HPV-positive oral cancers.

A key step would be to perform a natural history study that would follow people over a number of years and track in more detail how HPV-oral infections lead to cancer. This could help inform how to design a vaccine trial, Gillison said.

My job requires me to be online all day keeping an ear to the ground on major issues related to cancer. I knew the Prop 29 fight in California was going to be fought against Big Tobacco, but I didn’t realize the scale of their funding machine.

Why are LIVESTRONG, American Cancer Society, Campaign for Tobacco Free Kids, American Heart Association, American Lung Association and many other health organizations for this proposition? Because it keeps kids from smoking, funds much needed cancer research and prevention programs. So it won’t surprise you that Big Tobacco is the driving force against the cancer research prop. Although it is not surprising, the amount of money they are pumping into California is unreal. To date, Big Tobacco has funneled 40 million dollars into their anti cancer research initiative compared to Yes on 29 Coalition’s 8 million raised.

What I find most telling is when it comes to where these funds are from. Check out this visualization from MapLight.org – a nonprofit, nonpartisan research organization that reveals money’s influence on politics.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

May 9, 2012 — Actor Michael Douglas’ recent revelation that he has stage IV oropharyngeal cancer has highlighted the growing incidence of oral cancer, and experts say dentists can help stem the alarming increase of the disease by checking for it during routine examinations.

The actor’s cancer includes a walnut-sized tumor at the base of his tongue, and he will require radiation therapy, chemotherapy, and surgery. Douglas says his doctors told him he has an 80% survival rate if it hasn’t spread to his lymph nodes.

While tobacco was the prime cause of oral cancer in the past, recent studies have attributed the steady increase of the disease to the human papillomavirus (HPV). There are approximately 130 versions of HPV but only nine cause cancers, and the HPV16 version causes almost half of the oral cancers in the U.S., said Brian Hill, executive director of the Oral Cancer Foundation.

“Tobacco is no longer the only bad guy,” he told DrBicuspid.com. “HPV16 is increasing in incidence as the causative etiology, and if it continues on this trend line, it will replace tobacco as the primary cause of oral cancers.”

Dentists can play a key role in catching the disease in its early stages if they check for it during examinations, Hill pointed out. “But many dentists think it’s such a rare disease that they don’t bother to screen for it,” he said. “Most Americans have never even heard of oral cancer, but it’s not as rare or uncommon as people would like to think it is. This is why an opportunistic screening by the dental community is so important.”

Hill, a nonsmoker, got the same diagnosis as Douglas in 1998 and underwent radiation therapy, chemotherapy, and surgery. Since Hill’s oral cancer had metastasized to both sides of his neck by the time it was discovered, surgeons removed the right side of his neck to remove the lymph nodes there. He has been cancer-free for 10 years and said there are a lot of stage IV survivors out there.

“I’m on this side of the grass and that’s all that’s important,” he said, adding with a laugh, “I’m not pretty, but I’m still here.”

Changing demographics

Oral cancer screening tipsAccording to the Oral Cancer Foundation, an oral cancer screening includes a systematic visual examination of all the soft tissues of the mouth, including manual extension of the tongue to examine its base, a bimanual palpation of the floor of the mouth, and a digital examination of the borders of the tongue, and examination of the lymph nodes surrounding the oral cavity and in the neck.”Any sore, discoloration, induration, prominent tissue, irritation, or hoarseness that does not resolve within a two-week period on its own, with or without treatment, should be considered suspect and worthy of further examination or referral,” the foundation’s website states.The website also offers a more complete oral cancer screening protocol and a photo gallery showing various forms oral cancer can take.

In the last decade, the demographics of oral cancer have changed dramatically, according to Hill and other experts, pointing to the sexual revolution and accompanying increase in the prevalence of oral sex. Today almost half of those diagnosed with the disease are younger than 50 years old — with some as young as 20, according to Hill — and they are usually nonsmokers. According to the American Cancer Society, oral cancer occurs almost as frequently as leukemia and claims more lives than melanoma or cervical cancer. The incidence in oral cancer patients younger than age 40 has increased nearly fivefold, with many patients with no known risk factors, according to the ADA.

“Social and sexual behaviors have changed,” Hill said. “Oral sex is more common. The virus is spreading, especially among young people because sexual contact is more common, and this virus is not only ubiquitous in our society, but the mechanism of transfer is very simple.”

Until 2000, scientists were unsure if HPV caused oral cancer, Hill said, but definitive research in 2000 revealed it as a distinct etiology for the disease, and more recent studies have supported this finding.

The disease is dangerous because often there are no symptoms in the early stages that a person might notice. “It’s a very insidious disease,” Hill explained. He recalled that it was not until a lymph node became swollen that Hill realized something was wrong. Even then, it was not painful, he said.

But an alert dentist will notice subtle signs and symptoms in a simple three to five minute visual and tactile exam, Hill noted. “There will be things he’ll pick up on, and that’s why we’re urging that the dental community to become more involved in oral cancer screening,” he said.

Approximately 36,000 new cases of oral cancer are diagnosed each year in the U.S., according to the ADA, and some 25% of those people will die of the disease. Only 57% of all diagnosed oral cancer patients will be alive five years after their diagnosis, Hill said. Approximately 100 people in the U.S. will be diagnosed with oral cancer every day, he added, and one person will die every hour from it.

And when celebrities get oral cancer, it helps bring about much needed public awareness about the disease, said Hill, noting that, in addition to Michael Douglas, such luminaries as Sigmund Freud and Ulysses S. Grant have been among its victims.

“When somebody famous gets the disease, it finally gets the world’s attention,” he noted.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.